​Kembara Xtra - Medicine - Lichen Simplex Chronicus

​Kembara Xtra - Medicine - Lichen Simplex Chronicus 
A chronic dermatitis called lichen simplex chronicus (LSC) is brought on by persistent, frequent rubbing or scratching of the skin. Lichenification is the thickening and exaggerated wrinkling of the skin.
Skin system(s) impacted Synonym(s): localized neurodermatitis, lichen simplex, and neurodermatitis circumscripta

 Epidemiology
primarily affects middle-aged and older people.
Child Safety Considerations
in preadolescents rare
Peak incidence occurs between the ages of 35 and 50. Females outnumber males (2:1) in terms of occurrence. Prevalence Common


Pathophysiology and Etiology 

The cycle of itch and scratch results in persistent dermatosis.
Inflammation and pruritus are brought on by frequent scratching or rubbing, which in turn induces further scratching.
Scratching that is secondary to nonorganic pruritus, habit, or a conditioned reaction to stress or worry is known as primary LSC.
Common triggers include excessive skin dryness, heat, perspiration, and emotional stress.
The neurodermatitis that develops from a pruritic skin condition and persists even after the primary ailment has resolved is known as secondary LSC. Atopic dermatitis, contact dermatitis, lichen planus, stasis dermatitis, psoriasis, tinea, and insect bites are examples of precursor dermatoses.
●  Pruritus-specific C neurons are temperature sensitive, which may explain itching that occurs in warm situations. Radiculopathy or nerve root compression is a possible association between illness progression and underlying neuropathy.


Risk factors include irritable dermatosis, dry skin, insect bites, and anxiety disorders.

Basic Prevention 

Prevent typical triggers include psychological stress, extreme heat, and dryness, as well as skin irritability and the onset of pruritic dermatoses.

Associated Conditions
The nodular form of the same disease process is called prurigo nodularis.

Anxiety, sadness, and obsessive-compulsive disorders; Atopic dermatitis;

Background: Gradual onset
Most patients agree that they react by vigorously rubbing, itching, or scratching, which temporarily relieves the specific region of pruritus.
The majority of the time, pruritus is intermittent, gets worse at night, and can cause nighttime scratching.
 Can be asymptomatic, with the patient scratching while sleeping at night 

Clinical Assessment 

 Lichenification: accentuation of natural skin lines Well-circumscribed lichenified plaques with varied levels of overlaying excoriation or scaling It is possible to notice hyper- or hypopigmentation.
Scarring is uncommon with conventional LSC; it may appear after ulceration or subsequent infection. Most frequently, it affects places that are easily accessible. - Lateral regions of the ankles and lower legs - Lichen simplex nuchae on the nape of the neck - Vulva/scrotum/anus
- Palmar wrist - Scalp - Forearm extensor surfaces
Dermoscopic standards (for genital illness) - Diffuse arrangement - Rich vascularization, linear, serpentine, and dotted in shape - White-grayish background

Multiple Diagnoses 

 Extramammary Paget illness Lichen planus Lichen amyloidosis Tinea Nummular eczema Other systemic disease Lichen sclerosis Psoriasis Atopic dermatitis Contact, irritant, or stasis dermatitis Lichen amyloidosis Lichen planus Lichen amyloidosis Multiple myeloma, T-cell lymphoma, and lymphoma
- GI tract cancer, leukemia, and lung cancer

Laboratory Results 

Initial Tests (Lab, Imaging) No particular diagnostic test Microscopy (e.g., KOH prep) and culture preparation may be useful in identifying potential bacterial or fungal infection.
Other/Diagnostic Procedures
If the diagnosis is unclear, a skin biopsy may be performed. Patch testing may be used to rule out contact dermatitis.
Hyperkeratosis, acanthosis, lengthening of rete ridges, hyperplasia of all epidermal components, mild to severe lymphohistiocytic inflammatory infiltration, and significant lichenification are the test interpretations.

Patient education is essential for management.
If the patient is unable to refrain from scratching, there is a low chance that the condition will improve.

First Line of Medicine
Topical steroid medications are the first-line treatment for inflammation.
– The face, anogenital region, and intertriginous areas should not be treated with high-potency steroids alone, such as 0.05% betamethasone dipropionate cream or 0.05% clobetasol propionate cream, but they can be used initially. They should only be applied sparingly and for no more than two weeks, unless under the strict supervision of a doctor.
– As the body responds, switch to intermediate- or low-potency steroids.
– For initial, quick therapy of the face and intertriginous areas as well as for maintenance treatment of other locations, an intermediate-potency steroid, such as 0.1% triamcinolone cream, may be utilized.
– The face and intertriginous areas should be maintained with a low-potency steroid, such as 1% hydrocortisone cream.
– The steroid tape flurandrenolide has been tailored for penetration and acts as a deterrent against further scratching. Every day, switch out the cassette.
– For severe situations, intralesional steroids like triamcinolone acetate are also secure and productive.
Topical antipruritic medications can help prevent scratching.
- Oral first-generation antihistamines with sedative and antipruritic properties, such as diphenhydramine and hydroxyzine - Tricyclic sedatives for nighttime itching, such as amitriptyline and doxepin - The patient may have nighttime itching while they are asleep; in these situations, occlusive dressings may be useful.
ALERT
Topical steroids shouldn't be applied to the face, intertriginous areas, or anogenital region since they can induce pigmentary changes, dermal/epidermal atrophy, and atrophy of the skin's outer layers. Treatment for other body parts shouldn't go longer than three weeks without close medical supervision.

Next Line

every suggestion
Neurodermatitis has been successfully treated with topical aspirin.
5% doxepin cream applied topically exhibits strong antipruritic properties.
Early illness signs can benefit from topical capsaicin cream treatment.
 0.1% tacrolimus given twice daily for six weeks is an efficient substitute for chemotherapy.
In people who don't respond to steroids, gabapentin was proven to lessen symptoms.
Topical lidocaine has been shown to be successful in reducing neuropathic itching.
Patients with recalcitrant pruritus have reported that intradermal injections of botulinum toxin relieve their symptoms.
Transcutaneous electrical nerve stimulation may help patients whose pruritus was unaffected by topical steroid therapy.
NB-UVB was suggested as a potential off-label treatment for refractory LSC in a case report.
SSRIs might be useful in reducing obsessive scratching brought on by a mental diagnosis.

Referrals are made in the following situations: No response to treatment; the presence of symptoms and signs that point to a systemic cause of pruritus; consultation with a psychiatrist for patients who experience extreme stress, anxiety, or compulsive scratching; and consultation with an allergist for those who experience multisystem atopic symptoms. 

Additional Treatments
Silk underwear to reduce friction in genital LSC, psychotherapy, cooling of the skin with ice or cold compresses, soaks and lubricants to increase barrier layer function, bandaging or Unna boots, nail clipping


Alternative Therapies 

It has been demonstrated that acupuncture works well to treat pruritus.
Cognitive-behavioral therapy may increase awareness and aid in the discovery of coping mechanisms.
Hypnosis might help in reducing pruritus and avoiding scratching.
Thuja and graphite, two homeopathic treatments, have been applied.

Patient Follow-Up Monitoring
It is important to monitor patients for treatment response, side effects (particularly from topical steroids), and subsequent infections.
DIET A consistent, balanced diet

Patient Education – Patients should be aware of the underlying causes of this illness and the crucial part they play in its cure: Stress reduction approaches can be helpful for people for whom stress plays a role. - Stress that scratching and rubbing must stop for lesions to heal; treatments ineffective if scratching continues.
 Refrain from being around recognized triggers.

If the cycle of itching and scratching can be broken, the prognosis is good. After healing, the skin should resume its normal appearance, but it may also retain accentuated skin markings or postinflammatory pigmentary changes that may take some time to disappear.

Complications 
Consequences of  secondary infection, complications connected to therapy, as noted in drug precautions,Squamous cell carcinoma inside affected region,scarring without ulceration or subsequent infection.

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